The aims of the study were to evaluate the feasibility of the applied method, and to examine differences in the resuscitation performance between the first responders and the cardiac arr
Trang 1O R I G I N A L R E S E A R C H Open Access
In-hospital resuscitation evaluated by in situ
simulation: a prospective simulation study
Frederik Mondrup1*, Mikkel Brabrand1, Lars Folkestad1, Jakob Oxlund2, Karsten R Wiborg2, Niels P Sand3,4and Torben Knudsen4,5
Abstract
Background: Interruption in chest compressions during cardiopulmonary resuscitation can be characterized as no flow ratio (NFR) and the importance of minimizing these pauses in chest compression has been highlighted
recently Further, documentation of resuscitation performance has been reported to be insufficient and there is a lack of identification of important issues where future efforts might be beneficial By implementing in situ
simulation we created a model to evaluate resuscitation performance The aims of the study were to evaluate the feasibility of the applied method, and to examine differences in the resuscitation performance between the first responders and the cardiac arrest team
Methods: A prospective observational study of 16 unannounced simulated cardiopulmonary arrest scenarios was conducted The participants of the study involved all health care personel on duty who responded to a cardiac arrest We measured NFR and time to detection of initial rhythm on defibrillator and performed a comparison between the first responders and the cardiac arrest team
Results: Data from 13 out of 16 simulations was used to evaluate the ability of generating resuscitation
performance data in simulated cardiac arrest The defibrillator arrived after median 214 seconds (180-254) and detected initial rhythm after median 311 seconds (283-349) A significant difference in no flow ratio (NFR) was observed between the first responders, median NFR 38% (32-46), and the resuscitation teams, median NFR 25% (19-29), p < 0.001 The difference was significant even after adjusting for pulse and rhythm check and shock
delivery
Conclusion: The main finding of this study was a significant difference between the first responders and the cardiac arrest team with the latter performing more adequate cardiopulmonary resuscitation with regards to NFR Future research should focus on the educational potential for in-situ simulation in terms of improving skills of hospital staff and patient outcome
Keywords: cardiopulmonary resuscitation, simulation, in-situ simulation, no flow ratio, no flow time
Introduction
Recent investigations highlight the importance of
redu-cing interruptions in chest compressions and early
defi-brillation as vital factors of cardiopulmonary
resuscitation (CPR), and the European Resuscitation
Council 2010 Guidelines (ERC 2010) further emphasize
these elements [1-9]
Despite clear recommendations on CPR performance, several studies reports insufficient CPR quality during training (simulation) and during out-of-hospital and in-hospital cardiac arrests [10-14] Documentation of resus-citation management may be difficult in the acute situa-tion and it has been reported to be insufficient [15,16] Furthermore, the retrospective nature of documentation
in records represents a pitfall due to incompletion or inaccuracy [17] Documentation regarding precise timing
of events during resusciation, such as data concerning chest compressions and defibrillation, represents a pro-blem and data may be imprecise or not even available
* Correspondence: frederik.mondrup@gmail.com
1
Sydvestjysk Sygehus Esbjerg, Department of Emergency Medicine,
Finsensgade 35, DK-6700 Esbjerg, Denmark
Full list of author information is available at the end of the article
© 2011 Mondrup et al; licensee BioMed Central Ltd This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
Trang 2[16] Thus, a gap exists in documentation between first
responders and cardiac arrest team, and the inadequate
documentation may lead to misinterpretation in
resusci-tation performance Finally, data from patient safety
incidents and adverse event reporting systems suffers
from underreporting [18] Due to these problems, there
is a lack of identification of issues which need attention
and where future efforts might turn out to be beneficial
Medical simulation has become widespread and plays
a central role in teaching and in the assessment of
doc-tors and other health care professionals [19]
Simulation performed within a clinical enviroment, in
situ simulation, is particularly suitable to identify system
weaknesses or errors and to perform context-sensitive
assessments By bringing simulation into the clinical
enviroment, it is possible to identify and prevent adverse
events that could compromise patient safety [20-22]
Furthermore, in situ simulation represents a
cost-effec-tive opportunity in medical education and several
stu-dies report the utility of simulation training for
acquisition of skills and knowledge with retention across
different specialities [23-25]
By implementing in situ simulation to perform
unan-nounced in-hospital cardiopulmonary arrest, we created
a model to evaluate resuscitation performance
Our aims in this study were to: 1) evaluate the
feasi-bility of the applied method and afeasi-bility to generate
resuscitation performance data, 2) examine whether
there is a difference in the resuscitation performance
between first responders and the cardiac arrest team in
unannounced simulated scenarios
Methods
Design
The study was a prospective simulation pilot study
which evaluated the resuscitation performance during
simulated cardiac arrest The local ethical committee
was queried and the decision “ethical approval not
required” was given Danish law exempts this type of
research from ethical approval The board of the
hospi-tal and all involved heads of departments were informed
about the purpose of the study and gave their consent
to participate
Setting and participants
The study was conducted in a regional teaching hospital
with approximately 500 beds and an annual census of
approximately 43,000 patients
Data collection consisted of data registered during
unannounced simulated cardiac arrests in the period
April 2010 - June 2010 The simulations were conducted
in day-time only
The participants of the study involved all health care
personel on duty who are expected to respond to a
cardiac arrest This involves first responders, typically nurses or nurse-assistants who identify the cardiac arrest, call the cardiac arrest team and initiate basic CPR The cardiac arrest team assembles ad hoc and consists of a medical resident who serves as a team lea-der accompanied by a medical intern, an anesthesia resi-dent and nurse, and two orderlies The team is characterized by a wide disparity in clinical experience The role of the orderlies is to secure arrival of the defi-brillator, emergency equipment and to perform chest compressions
Scenario Setting
The study group developed four different on-site simu-lated scenarios with a resuscitation manikin Resusci Anne Simulator (Laerdal Medical®, Stavanger, Norway) for interdisciplinary resuscitation The Lifepak 12 (Med-tronic®, Redmond, United States of America) defibrilla-tor was used throughout the study and only in manual mode The scenarios were conducted in two units of the hospital (a surgical and a medical unit) and featured common causes to cardiac arrest e.g chest pain, hypoxia and hypovolemia
Furthermore, each scenario had pre-defined scripted branch-points from start to stop and included both shockable and non-shockable rhythms The scenarios would advance according to actions of the first respon-ders and the cardiac arrest team Finally, each scenario had a patient background file with a brief medical his-tory and test results to provide additional immersion
Sequence of events
The nurse manager of the ward was contacted in advance, and a room and a covering nurse were assigned All equipment including manikin, laptop, three remote controlled moveable cameras, and a microphone were quickly installed by a technician The nurse assigned to the room was introduced to the simulated patient and the medical history, and was instructed to intervene as one would do with a regular patient The scenario developed into cardiac arrest and the additional personnel assembling to the simulation were unaware of the ongoing mock event They were instructed to respond according to their clinical responsibilities upon arrival at the patient, e.g the first responders initiated basic resuscitation The scenario was ongoing and the first responders were released by the resuscitation team
as they arrived The assessment was performed in the two groups during the entire scenario At the end of the simulation, two members of the study group performed
a debriefing of the resuscitation Investigators monitored other emergencies to prevent conflict with real emer-gencies and in case of an acute situation during simula-tion, this would lead to immediate interruption of the
Trang 3scenario and data was discarded The investigators’ roles
were only observational and they would only interact
with the personnel in order to prevent hazardous
situa-tions e.g unsafe defibrillation and help to apply the
modified defibrillation pads
Data collection and processing
All performance data were collected with Laerdal PC
SkillReporting System version 2.0 (Laerdal Medical,
Sta-vanger, Norway)
We defined no flow time (NFT) as the time from the
onset of cardiac arrest (Time 0) to ROSC in which no
chest compressions were being performed
Further-more, we defined the no flow ratio (NFR) as the ratio
between NFT and the total time of cardiac arrest
(Time 0 to ROSC) [26] This represents the fraction of
time during resuscitation in which the circulation is
compromised
According to the ERC 2005 Advanced Life Support
(ALS) Guidelines interval between stopping
compres-sions and delivering a shock must be minimized [27]
We adjusted (NFTadj) for the time required for these
procedures and a maximum of 5 seconds was given to
rhythm analysis and 10 seconds to charge the
defibril-lator and shock delivery (when appropriate) per two
minutes cycle Ten seconds were allowed for pulse
checks every two minutes Hereby the NFTadj
repre-sents the potential for reducing time without
circula-tion and would ideally be zero according to ERC 2005
Guidelines [13] In addition we used the NFTadjto
cal-culate the NFRadj, which represents the fraction of
time during resuscitation with compromised
circula-tion excluding time to the abovemencircula-tioned obligate
maneuvers
Each resuscitation scenario was divided into 30-second
segments, and NFT were measured By using cameras
we were able to identify the exact change in time of first
responders and the cardiac arrest team as well as
deter-mination of return of spontaneous circulation (ROSC)
All personnel were identified and registered with unique
identification numbers to subsequently monitor any
repeated participation and to remain subject anonymity
and confidentiality
Finally, we determined the time from recognition of
cardiac arrest to initiation of CPR, the time to arrival of
the defibrillator in the room, and the time to the first
rhythm on the defibrillator Time span for the first
responders was defined as recognition of cardiac arrest
(time 0) to arrival of one physician and orderlies The
resuscitation team time span was defined from end of
first responders to completion of the scenario Time to
first rhythm on the defibrillator was defined as
recogni-tion of the cardiac arrest (time 0) to the first rhythm on
the defibrillator’s scope
Data analysis
All processed data from simulations was gathered using
a spreadsheet application, Excel 2003 (Microsoft Corp.) All statistical analyses were performed with SPSS 15.0 (SPSS Inc, Chicago) As data was not normally distribu-ted, data is presented as medians and interquartile ranges (25%- 75% percentile) We assessed differences in NFR using a nonparametric Mann-Whitney test P-values below 0.05 were considered statistically significant
Results
We conducted 16 simulations and data from 13 was col-lected since two simulations were excluded due to other emergencies, and one simulation due to failure of trans-ferring data
There was no repeated participation among the first responders or assisting nurses during the simulations One of the orderlies was involved in three different simulations The participation registration showed that one physician was involved in three simulations and two different physicians participated in two simulations each (data not shown)
Overall, cardiopulmonary resuscitation performance data from simulated scenarios are summarized in table
1 During simulations we recorded a median compres-sion rate of 117 comprescompres-sion min-1 (112-122) and the actual delivered compression min-1were 82 (78-87) We observed that initiating of CPR during simulation was performed with a median of 29 seconds (22-46) The defibrillator arrived in the room after median 214 sec-onds (180-254) and it was used to detect initial rhythm after median 311 seconds (283-349)
The median NFR for the entire simulation was 28% (23-31) and the adjusted median NFR (NFRadj) was 18% (13-22)
Table 1 Cardiopulmonary resuscitation quality markers obtained from unannounced simulated cardiac arrest (n = 13)
Overall simulation Percentiles Median 25 75 Compression rate (comp/min) 117 112 122 Compressions (actual comp given/min) 82 78 87 Time to initiating of CPR (sec) 29 22 46 Time to arrival of defibrillator in room (sec) 214 180 254 Time to first rhythm on defibrillator (sec) 311 283 349
CPR: Cardiopulmonary Resucitation NFR: no flow ratio; percentage of the time during resuscitation without chest compressions and spontaneous circulation.
Trang 4Comparison of NFR between the first responders and
the resuscitation teams are summarized in table 2 NFR
for the first responders was median 39% (32-46) versus
a median NFR 25% (19-29) for the cardiac arrest teams,
p < 0.001 NFRadjfor the first responders was a median
26% (22-38) versus NFRadjof 13% (11-17) for the
resus-citation teams, p < 0.001 We performed a revised
analy-sis without the simulations, which included repeated
presence of the same physician, and the results did not
change significantly (data not shown)
Discussion
There is, to our knowledge, no existing validated tool to
identify errors and accurate assessment of NFR during
CPR, due to a combination of practical restraints,
research and simulation limitations We achieved high
realism during the simulations in a clinically familiar
environment and thereby created an almost replication
of a true cardiac arrest incident Thus, we could
gener-ate data on simulgener-ated cardiac arrest response and
per-formance and made it possible to assess the quality
during the existing gap between first responders and
cardiac arrest team By using in situ simulation, we were
able to establish a feasible model for studying
unan-nounced simulated cardiac arrest scenarios in the
sys-tematic evaluation of cardiopulmonary resuscitation
performance We were able to objectively assess
perfor-mance with regards to initiation of CPR, NFR and
defi-brillation during simulation
The main finding of this study was a significant
differ-ence between the first responders and the cardiac arrest
team with the latter performing more adequate
cardio-pulmonary resuscitation with regard to NFR Other
interview- and survey-studies present similar findings
[28,29] The results highlight the importance of the first
initiated response as previously reported [20] We
moni-tored possible repeated staff participation and found no
individuals performing multiple simulations as first
responders In the resuscitation team there were two
individuals (one of the orderlies and one physician) who attended three simulations each We do not believe that this observation may explain the significant difference but it may tend to favour the no flow ratio in the resus-citation group due to familiarity of the study setup We performed a revised analysis excluding these simulations and the results did not change significantly The main reason for the difference in performance was not sys-tematically analysed but we observed a tendency in delaying initial CPR due to the performance of other tasks (data not shown) The difference could be due to lack of training and education, and this study might help clarify the first responders’ task and importance in future education and training of cardiac arrest
Surprisingly, we observed that the median time for arrival of the defibrillator was more than three and a half minutes which does not meet the current recom-mendations of two minutes [9] This could be due to the fact that the orderlies only have access to one cen-tral defibrillator instead of multiple defibrillators in care-fully selected locations in our hospital Furthermore, it took more than five minutes to deliver a connected and powered defibrillator An explanation could be unfami-liarity with the defibrillator despite training of the physi-cians We observed several problems with finding and applying cables and pads (data not shown) There is also
a risk that this could be due to the application of the modified study-pads
Limitations
There are several limitations in this study First, the study is an analysis of simulated resuscitations and we are aware that the simulations may not represent actual responses during real cardiac arrests As mentioned in the introduction, there is growing evidence that simula-tion can be used as a skills assessment tool By using standardized pre-scripted scenarios, we attempted to minimize the gap in translating results from simulation
to real life events We did not correlate data recorded from real cardiac arrest to assure concordance due to the numbers of simulations However, we observe data that seems comparable with data from previously pub-lished studies [13,14]
Secondly, participants may not have been fully immersed in the simulations due to e.g personal rea-sons This could bias the data towards giving perfor-mance of inferior quality and by artificially prolonging the initiation of CPR and time to first rhythm on defi-brillator due to unfamiliarity with the simulation (equip-ment and environ(equip-ment) There is also a risk that the staff performed better due to the Hawthorne effect [30] Thirdly, we only performed thirteen simulations which raise the possibility of producing non-representative data Some of the hospital staff may never have attended
Table 2 Comparison of no flow ratio (NFR) between first
responders and resuscitation team during unaccounced
simulated cardiac arrest (n = 13)
First responders Resuscitation team
Percentiles Percentiles Median 25 75 Median 25 75 p-value
NFR (%) 39 32 46 25 19 29 p < 0.001 †
NFR_adj (%) 26 22 38 13 11 17 p < 0.001 †
NFR: no flow ratio; percentage of the of the time during resuscitation without
chest compressions and spontaneous circulation.
NFRadj: no flow ratio_adjusted; percentage of the of the time during
resuscitation without chest compressions and spontaneous circulation
adjusted by subtraction of time allowed for rhythm and pulse check and
defibrillation (when appropriate).
† Mann-Whitney test
Trang 5the simulations and others several times due to staffing
assignments
Finally, we only conducted simulations on weekdays
during daytime which might represent a bias in the
resuscitation performance due to better staffing and
bet-ter-performing staff This applies to both first
respon-ders and the cardiac arrest team
Institutional impact
This study describes a model to monitor the quality of
cardiopulmonary resuscitation as well as a tool to
iden-tify and prevent adverse incidents that could
compro-mise patient safety By conducting multiple simulations,
we were able to generate objective resuscitation
perfor-mance data and were able to monitor and document the
quality of cardiac resuscitation and identify areas in
need of improvement and also detect problems which
would not have been found in other ways We generated
objective performance data during simulation and were
able to identify prolonged defibrillation times
concern-ing the physicians’ handling of the defibrillator We
observed an in-adequate first response and while
debriefing the exercises, we emphasized the importance
of chest compressions and rapid defibrillation
Further-more, these observations lead to a clarification of ward
staff instructions in order to perform and act as first
responders, and the experience was passed to the local
educational panel
Finally, our discoveries of prolonged defibrillation lead
to a local discussion of introducing automated external
defibrillators or multiple defibrillators
Perspectives
Future studies involving in situ simulation should
evalu-ate the educational interventions’ impact on
perfor-mance and whether it can be used to improve clinical
performance and hopefully improve patient outcome
Furthermore, educational studies should evaluate
para-meters such as leadership, communication and
team-work with standardised assessment tools such as
Cardioteam as these are calibrated and validated for in
situ simulation [31]
Finally, application of in situ simulation can provide
considerable information with identification of
system-level problems and performance assessment not only
in cardiac arrest resuscitation but also in other areas
of medical and surgical therapies Furthermore, in situ
simulation is suitable for identifying logistical and
operational problems in institutions as the ongoing
merging of emergency departments and new
exten-sions occur
In situ simulation can be used alone to generate more
precise data on timing of events together with
informa-tion concerning leadership, human factors and
operational and low-practical bed-side findings In com-bination with chart reviews and patient safety incident reports, these modalities can serve each other as com-plementary and reduce the risk of misjudgment system performance and lack of recognition of shortcomings as previously proposed [17]
Conclusion
In situ simulation provides a safe opportunity to investi-gate performance on an organizational as well as bed-side level We applied in situ simulation and were able
to assess cardiopulmonary resuscitation without com-promising patient safety, and we believe that in situ simulation could be used as a supplementary tool to assess cardiopulmonary resuscitation We observed an inadequate first response performance during simulated cardiac arrest with regard to no flow ratio and pro-longed defibrillation Future educational and organiza-tional interventions should focus on improving the quality of care during the early phase of resuscitation with regards to continuing chest compressions and early defibrillation as well as evaluating the educational inter-ventions’ impact on clinical performance and patient outcome
List of abbreviations CPR: cardiopulmonary resuscitation; ERC: European Resuscitation Council; NFT: no flow time; NFR: no flow ratio: ROSC: return of spontaneous circulation.
Acknowledgements
We thank all of the involved healthcare professionals for volunteering to participate in the study We would also like to thank Lars Ketelsen and Helle Andreassen at Laboratory for Clinical and Communicative Skills for providing audiovisual equipment and technical assistance during the study.
Author details
1 Sydvestjysk Sygehus Esbjerg, Department of Emergency Medicine, Finsensgade 35, DK-6700 Esbjerg, Denmark 2 Sydvestjysk Sygehus Esbjerg, Department of Anaesthesiology, Finsensgade 35, DK-6700 Esbjerg, Denmark.
3 Sydvestjysk Sygehus Esbjerg, Department of Cardiology, Finsensgade 35, DK-6700 Esbjerg, Denmark.4Institute of Regional Health Services Research, University of Southern Denmark, Denmark 5 Sydvestjysk Sygehus Esbjerg, Department of Medical gastroenterology, Finsensgade 35, DK-6700 Esbjerg, Denmark.
Authors ’ contributions
FM contributed to the conception and design of the study, the funding, the acquisition, analysis and interpretation of data, and contributed to the drafting the manuscript MB and LF contributed to the study conception and design, the acquisition, analysis and interpretation of data JO and KRW contributed in the acquisition of data as well as interpretation of data NPS and TK contributed to the study conception and design, analysis and interpretation of data All authors contributed to the revision of the manuscript and approved the final article for publication.
Competing interests There are no financial or non-financial competing interests for any of the authors The study was financed by the Karola Jørgensen ’s Research Foundation (Karola Jørgensens Forskningsfond) The sponsor had no role in the design and conduct of the study, the interpretation of data, or in preparation and approval of the manuscript.
Trang 6Received: 11 August 2011 Accepted: 6 October 2011
Published: 6 October 2011
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